Siminoff L A, Fetting J H, Abeloff M D
Johns Hopkins Oncology Center, Baltimore, MD.
J Clin Oncol. 1989 Sep;7(9):1192-200. doi: 10.1200/JCO.1989.7.9.1192.
Candidates for breast cancer adjuvant therapy must not only grapple with the concept of micrometastatic disease, but often must consider the benefits and risks of clinical trials and alternatives. We studied 100 consecutive patient-physician encounters about adjuvant therapy to determine how well we informed patients about benefits and risks and how clearly we recommended treatment. Evaluation included observation and audiorecording of encounters, patient- and physician-completed questionnaires, and patient interviews. Patient-physician agreement on the benefits and risks of adjuvant therapy was poor. Sixty percent of patients overestimated their chance of cure by 20% or more compared with the physician. Poor agreement was partially explained by the observation that patients and physicians exchanged little specific information. Furthermore, decision-making was compressed. Although this was the first meeting with a medical oncologist for 79 patients (79%), 82 (82%) made final decisions about treatment by the end of the meeting. Physicians clearly identified their recommended treatment. Patients generally followed the physician's recommendation, except when clinical trials were recommended. Only 45% of trial-eligible patients chose to participate in offered trials. Physician recommendations of clinical trials were not as effectively communicated as nontrial treatments. Nonstandard adjuvant regimens, similar to the experimental arm of some ongoing randomized trials, were recommended to 30% of patients, especially those with a poor prognosis. In essence, physicians acted as if the trial question was answered, thereby diminishing enthusiasm for the trial. The widespread recommendation of nonstandard regimens similar or identical to the experimental arms in ongoing trials suggests a serious lack of consensus on what questions to ask in clinical trials and whether or not those questions have been answered.
乳腺癌辅助治疗的候选患者不仅要应对微转移疾病的概念，而且通常还必须考虑临床试验的益处和风险以及其他替代方案。我们研究了连续100例关于辅助治疗的医患会面，以确定我们向患者告知益处和风险的程度以及我们推荐治疗的明确程度。评估包括会面的观察和录音、患者和医生填写的问卷以及患者访谈。医患在辅助治疗益处和风险方面的一致性较差。与医生相比，60%的患者高估了自己20%或更多的治愈机会。一致性差的部分原因是观察到患者和医生很少交流具体信息。此外，决策过程被压缩。尽管这是79名患者（79%）与医学肿瘤学家的首次会面，但82名（82%）患者在会面结束时就治疗做出了最终决定。医生明确指出了他们推荐的治疗方法。患者通常遵循医生的建议，除非推荐了临床试验。只有45%符合试验条件的患者选择参加提供的试验。医生对临床试验的推荐不如非试验治疗那样有效地传达。30%的患者被推荐使用非标准辅助治疗方案，类似于一些正在进行的随机试验的试验组，尤其是那些预后较差的患者。从本质上讲，医生的行为就好像试验问题已经得到解答，从而降低了对试验的热情。在正在进行的试验中，广泛推荐与试验组相似或相同的非标准方案，这表明在临床试验中应该提出哪些问题以及这些问题是否已经得到解答方面严重缺乏共识。
